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Key Features

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Essentials of Diagnosis
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  • Fever, cough, dyspnea

  • Abnormal chest examination (crackles or decreased breath sounds)

  • Abnormal chest radiograph (infiltrates, hilar adenopathy, pleural effusion)

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General Considerations
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  • Streptococcus pneumoniae is most common cause of bacterial pneumonia in children of all ages

  • Bacterial pneumonia usually follows a viral lower respiratory tract infection

  • Children with compromised pulmonary defense systems are at high risk for bacterial pneumonia

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Clinical Findings

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Symptoms and Signs
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  • Fever (over 39°C)

  • Tachypnea

  • Cough

  • Chest auscultation may reveal crackles or decreased breath sounds in the setting of consolidation or an associated pleural effusion

  • Extrapulmonary findings caused by pneumonia

    • Meningismus

    • Abdominal pain

  • Organism causing pneumonia may be responsible for other infections

    • Meningitis

    • Otitis media

    • Sinusitis

    • Pericarditis

    • Epiglottitis

    • Abscesses

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Differential Diagnosis
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  • Noninfectious pulmonary disease should be considered in the differential diagnosis of localized or diffuse infiltrates

    • Gastric aspiration

    • Foreign body aspiration

    • Atelectasis

    • Congenital malformations

    • Heart failure

    • Malignancy, tumors such as plasma cell granuloma

    • Chronic interstitial lung disease

    • Pulmonary hemosiderosis

  • When effusions are present, additional noninfectious disorders should be considered

    • Collagen diseases

    • Neoplasm

    • Pulmonary infarction

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Diagnosis

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Laboratory Findings
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  • An elevated peripheral white blood cell count with a left shift may be a marker of bacterial pneumonia

  • A low white blood cell count (< 5000/μL) can be an ominous finding

  • Blood cultures should be obtained in children admitted to the hospital with pneumonia

  • Sputum cultures may be helpful in older children capable of providing a satisfactory sample

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Imaging
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  • Radiography

    • Air space disease or consolidation in a lobar distribution suggests bacterial pneumonia

    • Interstitial or peribronchial infiltrates suggest a viral infection

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Diagnostic Procedures
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  • Bronchial brushing or washing, lung puncture, or open or thoracoscopic lung biopsy should be undertaken in critically ill patients when other means do not adequately identify the cause

  • Viral antigen immunofluorescent staining (DFA) and polymerase chain reactivity (PCR) technology has improved the ability to detect a wide variety of viral infections

  • Thoracocentesis should also be performed in a child with a pleural effusion

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Treatment

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  • Empiric antibiotic therapy should be considered if bacterial pneumonia is suspected

  • Children younger than 4 weeks should be treated with ampicillin and an aminoglycoside

  • Infants 4–12 weeks of age should be treated with intravenous ampicillin for 7–10 days

  • Children 3 months to 5 years of age should be treated with oral amoxicillin (50–90 mg/kg/dose) for 7–10 days

  • Children older than 5 years should also be treated with amoxicillin (50–90 mg/kg/dose) for 7–10 days

  • Macrolide antibiotics should be used if an atypical infection is suspected

  • Additional therapeutic considerations

    • Oxygen

    • Humidification of inspired gases

    • Hydration

    • Electrolyte supplementation

    • Nutrition

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Outcome

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Follow-Up
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  • Careful outpatient follow-up within 12 hours to 5 days ...

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